Telogen Effluvium With Dysesthesia (TED) Has Lower B12 Levels and May Respond to B12 Supplementation

We investigated a subtype of Telogen Effluvium associated with Dysesthesia, (TED) which was defined as the presence of Telogen Effluvium with severe itch, pain, soreness, burning, or formication in the absence of any inflammatory scalp disorder or medication associated with Telogen Effluvium or Dysesthesia. These are patients who present with a "burning" scalp or other dysesthesia associated with increased telogen hair shedding. Telogen Effluvium is not typically associated with any scalp symptoms.3 Other scalp dysesthesia studies have mentioned occasional patients in their study that were also diagnosed with Telogen Effluvium,1,2 but the clinical association of Scalp Dysesthesia and Telogen Effluvium has never been made as a distinct entity.

Post-infectious sensory neuropathy with anti-GT1a and GQ1b antibodies associated with cold urticaria.

A 64 years-old woman presented subacute onset distal paraesthesia concurrently with cold-induced urticaria, a rare form of physical urticaria. Both the disturbances developed a fortnight after an upper respiratory tract infection. EMG confirmed an exclusively sensory polyneuropathy, with prolongation of distal latencies and reduction of amplitudes. Anti-GQ1b and anti-GT1a antigangliosides antibodies were found in serum. The clinical workout included CSF analysis, cryoglobulin and paraprotein search, neurotropic infective agents, neoplastic markers and extensive autoimmune disease antibodies analysis, all of which resulted negative. Intravenous immunoglobulins were administered, leading to progressive resolution of the sensory disturbance, while a combination of steroid and anti-histaminics treatment was used for the urticaria. The positivity for anti-ganglioside search with an EMG pattern characterized by a mixture of demyelinating and axonal features may suggest a nodo-paranodopathy at early stages. This is the first case of an association between an acute sensory neuropathy and cold urticaria, two immune mediated conditions apparently due to very different hypersensitivity pathways. A proposed mechanism for the co-occurence of these two conditions is presented, whereas this case expands the clinical spectrum of autoimmune diseases associated with anti-GQ1b and anti-GT1a antibodies.

N-Terminal Pro-Brain Natriuretic Peptide (NT-proBNP) Levels are Increased in Patients With Transient Ischemic Attack Accompanied by Nonfocal Symptoms.

BACKGROUND: Transient nonfocal neurological symptoms may serve as markers of cardiac dysfunction. We assessed whether serum N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, a biomarker of cardiac disease, are increased in patients with transient ischemic attack (TIA) accompanied by nonfocal symptoms and in patients with attacks of nonfocal symptoms (transient neurological attack [TNA]). METHODS AND RESULTS: We included 15 patients with TNA, 69 with TIA accompanied by nonfocal symptoms, 58 with large-vessel TIA, 32 with cardioembolic TIA, and 46 age- and sex-matched healthy control participants. Serum NT-proBNP levels were determined within 1 week after the attack. We compared log-transformed NT-proBNP levels of patients with cardioembolic TIAs and mixed or nonfocal TNAs, with those of patients with noncardioembolic TIAs as a reference group. Adjustments for age, sex, atrial fibrillation, and a history of nonischemic heart disease were made with a multiple linear regression model. Compared with large-vessel TIA (mean 14.2 pmol/L), mean NT-proBNP levels were significantly higher in patients with TIA accompanied by nonfocal symptoms (40.5 pmol/L, P=0.049) and with cardioembolic TIA (123.5 pmol/L; P=0.004) after adjustments for age, sex, atrial fibrillation, and a history of nonischemic heart disease. Patients with TNA also had higher mean NT-proBNP levels (20.8 pmol/L, P=0.38) than those with large-vessel TIA, but this difference was not statistically significant. CONCLUSION: NT-proBNP levels are increased in patients with TIA accompanied by nonfocal symptoms.

An approach to the diagnosis and management of a case presenting with recurrent hypomagnesemia secondary to the chronic use of a proton pump inhibitor.

PURPOSE: Magnesium is an important electrolyte for very many cell functions and its deficiency may lead to a wide spectrum of diseases. We report a clinical case of hypomagnesemia resulting from the chronic use of a proton pump inhibitor (PPI). PPIs are drugs widely used in medical practice, and a growing number of cases of PPIs causing hypomagnesemia have been described. Our aim was to monitor the clinical and electrolyte findings during recovery from hypomagnesemia caused by long-term PPI use. RESULTS: A 65-year old female who had been using omeprazole for 10 years, presented with arrhythmia and paresthesia of the lower and upper limbs that had been attributed to severe hypomagnesemia, hypocalcemia, and hypoparathyroidism. Her laboratory tests revealed the following results: magnesium 0.6 mg/dL (NR: 1.5 to 2.5 mg/dL), calcium 7.3 mg/dL (NR: 8.5 to 10.2 mg/dL), parathyroid hormone (PTH) 13.3 pg/mL (NR: 15 to 65 pg/mL), and low urinary calcium and magnesium excretion. Her electrocardiogram disclosed typical, prolonged QT interval, ST depression, and U waves. We discuss the differential diagnoses, pathophysiology, and reversibility of symptoms after effective treatment of the hypomagnesemia. CONCLUSION: this report emphasizes that even if long-term PPI users appear largely asymptomatic, life-threatening arrhythmias can present very suddenly. Long-term PPI users should be monitored for otherwise unexplained hypomagnesemia, hypocalcemia, functional hypoparathyroidism and associated symptoms.

[When eating becomes dangerous...]. / Von der Frau, der das Essen nicht bekam.

We report the case of a 59-year-old women with idiopathic insulin auto-immune syndrome, a rare cause of endogenous hyperinsulinemic hypoglycemia. It is characterized by extremely high levels of insulin in the presence of high titers of insulin antibodies despite the absence of previous insulin injections. Early postprandial increase in glucose concentrations due to impaired insulin action resulting from the buffering effect of the antibodies and late postprandial hypoglycemia as a consequence of the dissociation of insulin from the antibodies was observed. A correct diagnosis is important to avoid unnecessary investigations and surgery in these patients who are best treated conservatively - with a good prognosis - by fractionating carbohydrate intake during the day.

The role of psychological factors and serum zinc, folate and vitamin B12 levels in the aetiology of trichodynia: a case-control study.

BACKGROUND: Cutaneous dysaesthesia syndromes are characterized by chronic cutaneous symptoms without objective findings, and their aetiologies are obscure. Trichodynia describes pain and a stinging sensation of the scalp related to diffuse alopecia. AIMS: To determine the prevalence rate of trichodynia in patients with diffuse alopecia; to assess the serum zinc, folate and vitamin B(12) levels; and to investigate the significance of psychological disorders in these patients. METHODS: The study comprised 91 patients with a diagnosis of diffuse hair loss and 74 healthy controls. Patients were questioned about the presence of trichodynia, and their serum zinc, folate and vitamin B(12) levels were assessed. They were also evaluated using the Beck Depression Inventory (BDI), the Beck Anxiety Inventory, and the Somatoform Dissociation Questionnaire (SDQ). RESULTS: The rates of androgenetic alopecia and telogen effluvium were 26.4% and 73.6%, respectively, Trichodynia was found in 30 patients (33%), and was more common in the telogen effluvium group than in the androgenetic alopecia group (P = 0.5). There was no significant difference between the patients with alopecia and controls for zinc, folate and vitamin B(12) levels, or for psychological test scores. However, the BDI and SDQ scores were significantly higher (P = 0.03 and P = 0.01, respectively) in patients with than those in without trichodynia. CONCLUSIONS: Trichodynia is a commonly encountered symptom in patients with diffuse alopecia, and depression and somatoform dissociation disorders may play an important role in its aetiology. Our data provide no evidence that serum levels of zinc, folate or vitamin B(12) are involved in the pathogenesis of trichodynia.

Randomized study on oral administration of calcitriol to prevent symptomatic hypocalcemia after total thyroidectomy.

BACKGROUND: Symptomatic hypocalcemia remains the main postoperative complication after total thyroidectomy. The aim of the present study was to evaluate the role of oral supplementation of calcitriol and calcium salts in preventing severe postoperative hypocalcemia after total thyroidectomy. METHODS: A consecutive series of patients undergoing total thyroidectomy followed by administration of 500 mg of calcium salts 3 times per day were randomized to 3 different postoperative medical treatments: in group A, .5 microg of calcitriol twice per day was administered to 104 patients; in group B, 1 mmicrog of calcitriol twice per day was administered to 111 patients; and in group C, 202 patients did not receive calcitriol. RESULTS: The rate of postoperative tetany in group A was 2.9%, in group B was 0%, and in group C was 7.4% (P=.03) and the rate of paresthesias was 28.8%, 17.1%, and 22.3%, respectively (P=.19). At discontinuation of calcitriol/calcium salts treatment, intact parathyroid hormone levels did not significantly differ from the preoperative levels. Receiver operating characteristic (ROC) curve analysis showed that the area under the curve for serum concentration of calcium in predicting postoperative tetany was .749, .858 and .862 on the first, second, and third postoperative day, respectively. The best cut-off value of calcemia for prediction tetany was 7.5 mg/dL, and the rate of severe hypocalcemia on the third postoperative day was 23.1% in group A, 9.9% in group B, and 27.2% in group C (P=.001). CONCLUSIONS: Oral administration of 1 microg of calcitriol twice per day and 500 mg of calcium salts 3 times per day after total thyroidectomy significantly decreases the risk of severe postoperative hypocalcemia.

[The effect of short-term hyperventilation on the concentration of ionized serum calcium]. / Einfluss einer kurzzeitigen Hyperventilation auf die Konzentration des ionisierten Serumcalciums.

BACKGROUND AND OBJECTIVE: Paraesthesias and carpopedal spasms on hyperventilation are explained by a reduction in ionised serum calcium (ISC). We tested whether 5-minute hyperventilation changes the concentration of ISC. SUBJECTS AND METHOD: Arterial blood samples were obtained via a small plastic catheter introduced into the femoral artery of ten healthy male volunteers (mean age 33 years) before, during and after 5 minutes of hyperventilation, which was achieved by deep and rapid breathing and considered adequate when the end-expiratory pCO2 had fallen to 2.5 kPA within the first minute and remained below this level during the remaining 4 minutes. These criteria were met in nine of the ten patients. The ISC concentration was measured with an ion-selective electrode, the pH, paCO2 and bicarbonate levels with an autoanalyser. RESULTS: Paraesthesias of the fingers and hand occurred in nine of the volunteers, carpopedal spasms in seven. Despite a definite rise in pH from 7.39 +/- 0.02 to 7.75 +/- 0.045, the concentration of ISC did not change significantly during the hyperventilation. CONCLUSION: Paraesthesias and carpopedal spasms which occur during hyperventilation are not caused by a fall in ionised serum calcium in arterial blood.

Hyperventilation in normal subjects. A clinical, gas-analytic and EMG study.

Clinical (paresthesiae and Trousseau's sign), EMG, blood biochemical (lactic acid and total Ca2+) and gas-analytic (pH, PCO2, PO2, HCO3) changes were studied during and after 5 min voluntary hyperventilation (HV) in 15 normal subjects. Paresthesiae and spontaneous motor activity were common manifestations (87% and 67% respectively) in our test. They were significantly related only to changes in pH, PCO2 and PO2, with paresthesiae arising earlier and at milder gas-analytic changes than motor activity. Paresthesiae and motor activity induced by HV cannot be used as reliable indicators of pathology. Their presence simply reflects the degree of the blood gas-analytic changes (pH, PCO2 and PO2) which therefore should be carefully monitored before drawing any conclusion from an HV test.

Delayed appearance of anti-myelin-associated glycoprotein antibodies in a patient with chronic demyelinating polyneuropathy.

A patient who had a polyneuropathy compatible with a chronic inflammatory demyelinating polyneuropathy and was initially negative for anti-myelin-associated glycoprotein (MAG) antibodies developed a double monoclonal gammopathy, IgM kappa and IgM lambda, two years after the diagnosis. The IgM kappa, but not the IgM lambda, exhibited strong anti-MAG antibody activity. The late appearance of the anti-MAG immunoreactivity suggests that in patients with an initial diagnosis of chronic inflammatory demyelinating polyneuropathy, the search for anti-MAG antibodies should be repeated during the course of the neuropathy.

[Transcutaneous oximetry in symptomatic diabetics]. / Ossimetria transcutanea in pazienti diabetici sintomatici.

In a group of 33 patients affected by diabetes mellitus transcutaneous oxygen tension (PtcO2) was measured by means of a Clark polarographic electrode. Patients were divided into 3 groups according to the symptoms and/or to the clinical findings: group A: paresthesia (22 limbs); group B: claudication (6 limbs); group C: rest pain and/or necrosis (13 limbs). Moreover, group C was divided into: C1 trophic neuropathy lesion (7 limbs) and C2 trophic ischemic lesion (6 limbs). Our data point out that there is a statistically significant difference between mean PtcO2 values in limbs with trophic ischemic lesions versus the other 3 groups. Therefore, PtcO2 is particularly indicated and useful in the study of diabetic patients with peripheral vascular disease where integrates the other instrumental noninvasive techniques.

Transketolase inhibition and uremic peripheral sensory neuropathy.

The relationships between predialysis and postdialysis erythrocyte transketolase activities and symptoms of uremic peripheral neuropathy were studied prospectively for 21 months in 19 chronic hemodialysis patients. In all patients the predialysis activity was observed to be sometimes greater and sometimes less than the postdialysis activity. These observations were interpreted as indicating the coexistence in uremic blood of stimulatory and inhibitory substances which influence the enzyme independently. After enzyme stimulation was assumed to be a constant feature of uremia, the expected stimulated activity in erythrocytes of predialysis blood was found to be variably inhibited up to about 55% in these patients. The occurrence of paresthesiae was closely correlated with prolonged erythrocytes transketolase inhibition which in most cases reached a level of about 40%. Our conclusion is that the magnitude of erythroycte transketolase inhibition above a certain minimum level, together with its duration, is associated with symptoms of sensory peripheral neuropathy in the uremic patient. It is therefore predicted that such measurements may be usefully applied in ascertaining the extent of hemodialysis needed to prevent the development of this pathological state.